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An Outbreak of Escherichia coli O157:H7 Infection from Unpasteurized Commercial Apple Juice
- Sara H. Cody, MD;
- M. Kathleen Glynn, DVM, MPVM;
- Jeff A. Farrar, DVM, MPH, PhD;
- K. Lisa Cairns, MD, MPH;
- Patricia M. Griffin, MD;
- John Kobayashi, MD;
- Murray Fyfe, MD, MSc, FRCPC;
- Richard Hoffman, MD, MPH;
- Arlene S. King, MD, FRCPC;
- Jay H. Lewis, BS;
- Balasubr Swaminathan, PhD;
- Raymond G. Bryant, BA; and
- Duc J. Vugia, MD, MPH
- From California Department of Health Services, Berkeley, Sacramento, California; Centers for Disease Control and Prevention, Atlanta, Georgia; Washington State Department of Health, Shoreline, Washington; British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Laboratory Centre for Disease Control, Health Canada, Ottawa, Ontario, Canada; and Colorado Department of Public Health and Environment, Denver, Colorado.
Abstract
Background: Escherichia coli O157:H7 infections have traditionally been associated with animal products, but outbreaks associated with produce have been reported with increasing frequency. In fall 1996, a small cluster of E. coli O157:H7 infections was epidemiologically linked to a particular brand (brand A) of unpasteurized apple juice.
Objective: To define the extent of the outbreak, confirm the source, and determine how the apple juice became contaminated.
Design: Descriptive epidemiologic study and traceback investigation.
Setting: Western United States and British Columbia, Canada.
Patients: Patients with E. coli O157:H7 infection who were exposed to brand A apple juice.
Measurements: Clinical outcome and juice exposure histories of case-patients, pulsed-field gel electrophoresis of case and juice isolates, and juice production practices.
Results: Seventy persons with E. coli O157:H7 infection and exposure to brand A unpasteurized apple juice were identified. Of these persons, 25 (36%) were hospitalized, 14 (20%) developed the hemolytic uremic syndrome, and 1 (1%) died. Recalled apple juice that was produced on 7 October 1996 grew E. coli O157:H7 with a pulsed-field gel electrophoresis pattern indistinguishable from that of case isolates. Apple juice produced on 7 October 1996 accounted for almost all of the cases, and the source of contamination was suspected to be incoming apples. Three lots of apples could explain contamination of the juice: Two lots originated from an orchard frequented by deer that were subsequently shown to carry E. coli O157:H7, and one lot contained decayed apples that had been waxed.
Conclusions: Standard procedures at a state-of-the-art plant that produced unpasteurized juices were inadequate to eliminate contamination with E. coli O157:H7. This outbreak demonstrated that unpasteurized juices must be considered a potentially hazardous food and led to widespread changes in the fresh juice industry.
- Escherichia coli O157
- Escherichia coli infections
- Apple juice
- Sterilization
- Hemolytic-uremic syndrome
Article and Author Information
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Acknowledgments: The authors thank E. Russell Alexander and Janice Boase (Seattle-King County Department of Public Health) for providing the results of their case–control study and for initiating the investigation that followed; Mansour Samadpour (University of Washington) for rapid subtyping of specimens, which allowed early detection of the outbreak; Helen Hamoaka (Fresno District Office of the Food and Drug Administration) for leading the plant investigation; Andrew Bound (Food and Drug Administration Laboratory, Seattle) for isolation of the E. coli O157:H7 organism from a juice sample; William Bibb, Peggy Hayes, and Nancy Strockbine (Centers for Disease Control and Prevention) for performing the serologic, subtyping, and PCR studies, respectively; Sharon Abbott, Greg Inami, and Janet Mohle-Botani (California Department of Health Services) for subtyping of clinical specimens, testing of environmental samples, and case findings, respectively; Pamela Shillam (Colorado Department of Public Health and Environment) for case investigation; and Lyn Dupré, Douglas Owens, and Andrew Pelletier for comments on the manuscript.
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Requests for Reprints: Sara H. Cody, MD, Disease Prevention and Control, Santa Clara County Department of Public Health, 2220 Moorpark Avenue, #115, San Jose, CA 95128.
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Current Author Addresses: Dr. Cody: Disease Prevention and Control, Santa Clara County Department of Public Health, 2220 Moorpark Avenue, #115, San Jose, CA 95128.
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Dr. Glynn: Division of Public Health Surveillance and Informatics, Epidemiology Program Office, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop C-08, Atlanta, GA 30333.
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Dr. Farrar: Food and Drug Branch, California Department of Health Services, 601 North 7th Street, Sacramento, CA 94234.
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Dr. Cairns: Epidemiology Program Office, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop D-18, Atlanta, GA 30333.
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Drs. Griffin and Swaminathan: Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop A-38, Atlanta, GA 30333.
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Dr. Kobayashi and Mr. Lewis: Washington State Department of Health, 1610 Northeast 150th Street, Shoreline, WA 98155.
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Drs. Fyfe and King: British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, British Columbia V52Z 4R4, Canada.
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Dr. Hoffman: Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive, Denver, CO 80246.
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Mr. Bryant: Microbial Diseases Laboratory, California Department of Health Services, 2151 Berkeley Way, Berkeley, CA 94704.
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Dr. Vugia: Division of Communicable Disease Control, California Department of Health Services, 2151 Berkeley Way, Berkeley, CA 94704.
- Copyright ©2004 by the American College of Physicians
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